Using systematized tacit knowledge to prioritize implementation challenges in existing maternal health programs Dra. Jacqueline Alcalde Mtro. Victor Becerril National Institute of Public Health (México) 1

Background Maternal mortality is still a global health concern Despite numerous policies and programs only a few countries reached MDG5 – 75% reduction of maternal mortality between 1990 and 2015 In 2013, the maternal mortality ratio in developing regions was 14 times higher than in developed regions Mexico and Nicaragua, did not meet MDG5

Where are Mexico and Nicaragua located ?

Implementation research Two approaches Implementation research Tacit Knowledge

Implementation research In low and middle income countries, even when policies and programs are usually designed based on available evidence, it is not common to find evidence on how interventions are implemented. Implementation Supplies Results Maternal programs Health facilities In low- and middle-income countries (LMICs), although the design of policies and programs is increasingly based on available scientific evidence, it is not yet very common to find evidence-based decision making about the implementation of public health interventions(Gonzalez-Block et al. 2008; 2011). Human resources

Tacit Knowledge Knowledge and views derived from the direct experience of the diverse stakeholders participating in maternal health programs. They are near to the implementation problems Everyone has their own knowledge

Objective To assess the feasibility of using the tacit knowledge methodology to prioritize challenges to implementation of current maternal health programs and inform the post MDG agenda in LMICs.

Methodology Creation of six communities of practice (CoPs) in three states of Mexico and three departments of Nicaragua Managers Champion Facilitator Researchers Personnel in contact with patients

Methodology 2. CoPs receive training in face-to-face and online workshops 3. Concept Mapping was used to obtain CoP´s tacit knowledge First workshop: Initial brainstorming to answer the focus question: What are the main problems of the state or departmental health system that represent an obstacle to reach the expected results of your maternal health programs? Second workshop: Training on the use of the Concept Systems Global online platform Online activities: a) sorted the 98 statements in conceptual groups following his or her own criteria b) rated each statement according to its importance and the feasibility of solving it 4. We generated conceptual clusters using multi dimensional scaling and a correlation matrix

Metodología – Comunidades de práctica Idea idea Tacit knowledge idea IDEAS idea idea idea Comunity of practice

Plattform Concept Systems Global Concept mapping Sub-grupo 4 Lluvia de ideas On line Plattform Concept Systems Global Sub-grupo 3 Lluvia de ideas Sub-grupo 2 Lluvia de ideas Sub-group 1 Brainstorming Integración de ideas por estado Integración de ideas por estado Final pool of problems 98 Sub-grupo 4 Lluvia de ideas Integración de ideas por estado Sub-grupo 3 Lluvia de ideas Pool of Problems by CoP and country Sub-grupo 2 Lluvia de ideas Sub-group 1 Brainstorming Rating of each statement according to its importance and feasibility of solution Sub-grupo 4 Lluvia de ideas Sub-grupo 3 Lluvia de ideas Sub-grupo 2 Lluvia de ideas Sub-group 1 Brainstorming Elimination of duplicates and redundancies n = 202 participants Mexico = 82 Nicaragua = 120 6 CoPs Sub-grupo 4 Lluvia de ideas Sub-grupo 3 Lluvia de ideas Sub-grupo 2 Lluvia de ideas Sub-group 1 Brainstorming

Concept Map – Points map 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 Sorting exercise, we generated clusters or conceptual groups using multidimensional scaling and a correlation matrix

Results Concept map – 10 clusters 1 2 3 12 14 23 25 26 42 46 48 52 56 62 72 76 86 96 5 30 43 49 73 87 89 9 19 20 21 47 74 75 4 7 10 16 24 32 34 61 71 80 88 6 8 11 35 36 67 69 13 15 17 33 37 39 40 53 60 65 68 92 94 97 18 28 29 31 57 58 59 63 77 78 81 82 83 93 22 45 50 51 55 84 38 41 85 90 91 95 27 44 54 64 66 70 79 98 1. QUALITY OF HEALTH CARE 2. EXCESS OF PATIENTS DEMAND 3. ARTICULATION BETWEEN FIST AND SECOND CARE LEVELS 4. SOCIAL AND EDUCATIONAL LEVEL 5. PERCEPTION OF USERS ABOUT HEALTHCARE 6. LACK OF HUMAN AND FINANCIAL RESOURCES 7. FINANCE INFORMATION 8. CORRESPONSABILITY OF MUNICIPAL AUTHORITIES IN MATERNAL HEALTH 9. PROMOTION AND SOCIAL PARTICIPATION 10. LACK OF FACILITIES FOR PREGNAT WOMEN Results Concept map – 10 clusters

Concept map – Importance rating

Concept map – Feasibility rating

Correlation Diagram: Importance – Feasibility

Priorities FACTIBILIDAD DE RESOLUCION IMPORTANCIA 4.04 3.55 2.6 3.4 1 Consultations for risk pregnancies are established in distant dates and even after the delivery date 2 Deficient valuation of pregnant women by the personnel who receives them (physicians and nurses) 3 Negative attitude during care of personnel towards pregnant women 6 Pregnant women and their families fail to make a timely detection of alarm signs 12 Bad reception of pregnant women in emergency cases by surveillance personnel in health units 13 Problems with the distribution of delivery care inputs 14 Deficient quality of care during pregnancy, delivery and postpartum 23 High rate of refusal of care for pregnant women in health units 25 Lack of follow-up of postpartum by health care personnel 26 Lack of compliance to Official Norms and Practice Guides 35 Pregnant women fail to attend to antenatal control 42 Long waiting time for pregnant women’s care in health units 46 Inadequate follow-up of obstetric complications 48 Inadequate identification of obstetric risk by health personnel 49 Lack of follow-up and evaluation of maternal health care processes 56 Lack of human attitudes in health personnel responsible for pregnant women’s care 58 Obstetric emergency and general care equipment is in bad conditions 72 Limited follow-up of pregnant women in the first level of care 77 Lack of drugs for normal and emergency obstetric care 86 Lack of follow-up in pregnant women’s care to guarantee an integral care 87 Human resources for health are badly trained during their studies 89 Health personnel lacks training 90 Sexual education programs for adolescents are not implemented 91 Community personnel linked with maternal health programs lacks training 96 Negligence on the part of health personnel 1 2 3 6 12 13 14 23 25 26 35 42 46 48 49 56 58 72 77 86 87 89 90 91 96 4 8 9 10 16 17 18 22 24 28 30 31 32 34 38 40 50 52 55 66 67 74 75 84 85 92 94 98 5 7 11 15 27 33 36 39 41 43 44 45 53 54 60 62 68 69 70 71 73 76 79 80 82 95 97 19 20 21 29 37 47 51 57 59 61 63 64 65 78 81 83 88 93 4.04 3.55 2.6 3.4 3.97 4.52 r = 0.44 FACTIBILIDAD DE RESOLUCION IMPORTANCIA

Conclusions Tacit knowledge is a feasible and potentially valuable approach to improve the implementation of programs. To involve health personnel and decision makers in research legitimizes the research results. This innovative approach can significantly contribute to improve the quality and accessibility of health services